results: the staff safety assessment survey lisa lubomski, phd april 11, 2013

Results: The Staff Safety Assessment Survey

Lisa Lubomski, PhD

April 11, 2013

The Staff Safety Assessment Survey

You spoke…and we listened.

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Participants

There were:

• 46 participants in total

• 35 participants from Maryland

• 11 participants from Pennsylvania

Thank you for participating!

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The Premise

We asked you to please describe how the

next patient in your unit/clinical area will

be harmed, and to present solutions to

prevent or minimize harm.

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Response: Potential Harm

Each response and solution to fell into

6 main categories:

1. Falls

2. Miscommunication

3. Lack of Staff

4. Hospital Acquired Infection

5. Medication Error

6. Other Adversities

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Problem and Solutions

Addressing each potential harm

category with the solutions you have

proposed.

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Problem 1

Falls:

• can cause an adverse event leading to patient harm

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Falls

Solutions Proposed:

• adequate staff present when tending to patients

• increase number of bed alarms, designate sitters for

high risk patients, have safe lifting equipment available

• implement preventative measures (ex. proper socks,

yellow band, low bed, et al.)

• improved staff communication

• increase frequency of rounds for high risk patients

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Problem 2

Miscommunication:

• causes delayed care

• leads to instructions not being followed

• leads to ignoring others (especially subordinates)

• causes unnecessary procedures for patients

• causes failure to obtain consent

• lack of physician engagement

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Miscommunication

Solutions Proposed:

• work to improve communication overall

• implement a clear chain of command - with specific

duties assigned

• have a checklist with pertinent patient information readily

available

• listening to the concerns of others (regardless of rank)

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Miscommunication

Solutions Proposed continued:

• only perform necessary procedures for patients

• proper patient screening with informed consent a

priority

• ongoing meetings with VP of quality to ensure

physician compliance with bundles and care planning

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Problem 3

Lack of Staff:

• adverse event leading to patient harm

• places too many responsibilities per staff member

• late/delayed care or administration of medication

• mistakes due to fatigue

• mistakes by new staff member

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Lack of Staff

Solutions Proposed:

• increasing number of staff (ex. RNs, CCTechs, et al.)

• implement a clear chain of command - with specific duties

assigned

• implement a grassroots campaign to increase staff

numbers

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Lack of Staff

Solutions Proposed continued:

• ongoing education for personnel, and ensuring an

experienced staff member is working at any given time

• have a contingency plan for increasing available staff in

the event of a sudden influx of patients

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Problem 4

Hospital Acquired Infection:

• cause adverse event leading to patient harm

• caused by poor hand-washing practices

• can cause VAP- makes it more difficult to extubate,

leads to longer time in critical care, increases

probability of additional infections

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Hospital Acquired Infection

Solutions Proposed:

• continued education for staff -emphasizing the spread of

pathogens and good hand-washing practices

• monitoring compliance for good hand-washing practices

• increased accessibility of hand hygiene products coupled

with visible cues and reminders

• improved maintenance of central line

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Hospital Acquired Infection

Solutions Proposed continued:

• early mobility of patients

• implementation of a strict daily device assessment tool

• preventative care- while on ventilator follow

recommendations for oral care, HOB 30 degrees,

sedation vacation, among other tools

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Problem 5

Medication Error:

• can cause an adverse event leading to

patient harm

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Medication Error

Solutions Proposed:

• pharmacy and medication monitoring

• no override of medications until front-line staff

approval is obtained

• need a pharmacist working in ICU 24/7

• identification of common dosing conversions and unit

conversions

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Problem 6

Other Adversities:

• outdated equipment

• illness-related death

• inconsistent care practices

• lack of resources

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Other Adversities

Solutions Proposed:

• standardize equipment across units

• improved vigilance and monitoring of patients

• implement standardized protocol and daily rounds

checklist

• more resources needed

Thank you all very much!

The Next Step…

Learning from Defects!

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